Provider Demographics
NPI:1124424544
Name:MCCULLOUGH, CLAIRE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:CLAIRE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:CLAIRE
Other - Middle Name:
Other - Last Name:CELLARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:181 ASHDOWN RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-2338
Mailing Address - Country:US
Mailing Address - Phone:518-775-8279
Mailing Address - Fax:
Practice Address - Street 1:70 MALTA AVE
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-1599
Practice Address - Country:US
Practice Address - Phone:518-775-8279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program